It has been documented that 1 in 3 women will experience rape in her lifetime, and this is most common in women under the age of 25. Over 95% of victims of sexual assault are women worldwide, while in North America estimates place that at 85%. These are the assaults we know about – generous estimates say that, at most, 10% of rapes are reported to police or other authorities/health care providers. 2004 CDC statistics indicated there were 57,000 visits to US emergency departments for a presenting complaint of sexual assault – which is still a high number despite flawed methodology which likely vastly underestimated the numbers. To support this, a 2014 survey of patients in the emergency department found that half had experienced sexual assault in their lifetime. Sexual assault has an annual cost of over $2 billion in direct patient costs, lost wages and productivity (not including childhood sexual abuse).

Sexual assault affects all domains of a victim’s life, the physical and emotional, and extends out in a ripple effect to their surrounding relationships. This has been shown to be a key factor in the health of a person, exacerbating chronic complaints and contributing to new medical issues. It can be difficult for a patient to disclose their assault due to shame, guilt, feelings of responsibility and cultural norms. Instead, they can present with vague complaints which can be acute or chronic in nature – commonly headache, abdominal/pelvic pain, anxiety, depression and substance abuse. We under-recognize sexual trauma, both acute and historical, as a key contributor to their current ED presentation.

Assault is part of a patient’s medical and life history, and should be taken into consideration during their clinical assessment. One way to identify these patients is to recognize pattern injuries such as bruising, swelling or abrasions that don’t fit the story or fit a concerning pattern – we are very good at recognizing the hallmarks of child abuse, but don’t translate it in our minds when outside the pediatric age group! Be mindful of “branding” – tattoos such as bar codes or names that are used to identify a victim of human trafficking in a visible location such that those in the industry can recognize their “property”. The ED is often the only point of refuge for those patients, and we have a unique opportunity to help them. Many of these patients are relieved to see a female physician.

One of the major barriers that has been found to asking about sexual violence is not knowing what to do when someone discloses a history of sexual assault. What do you do? After disclosure, there may be a variety of different emotional responses, much like any grief reaction. They may have tears, may be angry or may be numb. There are certain mandatory reporting requirements, such as the notification of Child Protection/Children’s Aid, and others that vary by jurisdiction. Care of these patients is complex, involving medical, forensic and emotional aspects. It is also a high stakes patient interaction as the legal case can hinge on quality of evidence collected, with very high standards for documentation and maintenance of chain of evidence for intersection with legal system. This is also time-consuming, typically taking hours to complete the medical and forensic care – which is impossible in a busy ED! Many EDs have direct linkages to specialized sexual assault care programs staffed with highly trained Sexual Assault Nurse Examiners (SANE) who can assume the care for these patients.

To find out who your local resource is, search the International Association of Forensic Nurses web directory at www.forensicnurses.org. Contact your local program and speak about the patient directly – you can communicate any concerns you have and collaborate to find the safest solution to get your patient to them. This may be the moment of intervention for this assault victim. It isn’t enough to give them a phone number or a location and ask them to reach out – they need an advocate for their care who will get them to their destination safely and reliably.

This is a patient population that needs a champion at each site – to provide education to clinical staff on screening and recognition of the signs of abuse, and to emphasize the reality of the numbers of patients they are seeing daily that this affects. It is also key to educate your hospital as an institution such that they recognize the scope of the problem, and know where to send patients that they encounter in non-emergency room locations (such as Obstetrics and Orthopedics), or where to go themselves if they have experienced sexual violence.

Advocacy can take shape in many forms. What can you do to care for and prevent sexual assault in your community?

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